Integrated Health Care Subsystem for Federal Public Servants assessments: asymmetry in decisions of health professionals and the contradiction of the system

Abstract

Health claims from federal civil servants in the Executive Branch are evaluated by medical experts, according to the guidelines of the Integrated Health Care Subsystem for Federal Civil Servants (SIASS), since its implementation in 2009. The system allows only doctors and dentists to sign reports. This is despite the fact that, when SIASS was implemented, interdisciplinarity and the non-hegemony of medical knowledge were fundamental principles. This essay seeks to discuss the possible contradiction in the system, with regard to the decision of claims that reach the medical examiner. The contradiction refers to the asymmetry in the technical decisions of the claims, which are mainly concentrated in physicians to the detriment of interdisciplinarity. The discussion was based on the theoretical framework of Occupational Health, and the essay sought to understand the ramifications of the aforementioned contradiction, highlighting possible collective and individual damages resulting from a restrictive view, such as the invisibility of causal links offered by other non-medical professionals in the system, obscuring possible causes of illness. It also has personal consequences for civil servants, such as disability pensions without recognition of their relationship with occupational accidents and diseases.

Keywords
Occupational Health; Medical Expert Office; Interdisciplinarity

Resumo

Os pleitos em saúde de servidores públicos federais do Poder Executivo são avaliados por peritos médicos, conforme diretrizes do Subsistema Integrado de Atenção à Saúde do Servidor Público Federal (SIASS), desde sua implantação, em 2009. O sistema só permite a assinatura de médicos e odontólogos nos laudos. Isso ocorre apesar de, na implantação do SIASS, a interdisciplinaridade e a não hegemonia do saber médico terem sido princípios basilares. Este ensaio busca discutir essa possível contradição no sistema, no que tange à decisão dos pleitos que chegam à perícia médica. A contradição refere-se à assimetria nas decisões técnicas dos pleitos, que se concentram majoritariamente nos médicos, em prejuízo à interdisciplinaridade. A discussão foi calcada no referencial teórico da Saúde do Trabalhador e o ensaio buscou compreender os desdobramentos da contradição referida, ressaltando possíveis prejuízos coletivos e individuais decorrentes de uma visão restritiva, como a invisibilidade de nexos de causalidade indicados por outros profissionais, não médicos, do sistema, obscurecendo possíveis causas de adoecimento. Também traz consequências pessoais para servidores, como as aposentadorias por invalidez sem reconhecimento de sua relação com acidentes e doenças do trabalho.

Palavras-chave
Saúde do Trabalhador; Perícia Médica; Interdisciplinaridade

Health care for federal civil servants and medical examinations: history and assumptions

The aim of Occupational Health is to guide interventions in occupational health-disease processes. It emerged in Brazil during the democratic transition, a circumstance that led to the Brazilian health reform movement in the late 1970s¹. This perspective brought together efforts to consider the conditions, relations and organization of work in the prevention of illnesses and in understanding the processes of worker illness, based on social movements and seeking to invoke the right to health in terms of full citizenship².

In relation to the paradigms adopted previously (Occupational Medicine and Occupational Health), Workers’ Health includes, in its understanding of the health-disease relationship, the subjectivity of the worker inserted in a work organization that brings to light problems situated beyond physical, chemical and environmental risk factors. The field begins to consider the social determinants of health-disease processes, including the dimension of “class” as a constitutive element of these determinants and therefore broadening the “interpretative framework of disease”³. Moreover, this field seeks interdisciplinary action and the non-hegemony of medical knowledge as well as of any other sphere of knowledge. In the process of identifying harmful work environments, it seeks to highlight the worker as the subject of health policies, removing them from the position of object of intervention⁴,⁵. They are the ones who, beyond the prescribed tasks, know their job and the reality that surrounds it, made up of a series of invisible and complex activities which, as scholars of activity ergonomics⁶pointed out, are not performed for an outside observer.

The assumptions of Occupational Health were systematized in Brazilian legislation by means of Ordinance No. 1^,823/2012⁷(National Occupational Health Policy - PNSTT) and constituted the principles for the implementation of the Integrated Health Care Subsystem for Civil Servants (SIASS). Since 2009, when it replaced the Integrated Occupational Health Subsystem for Federal Civil Servants (SISOSP), SIASS has provided health care for federal public servants in the Executive Branch.

Looking back at the history of the regulation of aspects related to health and work in Brazil, its clearest foundations can be found in the Federal Constitution (1988). In relation to federal civil servants, this gave rise to the implementation of Law No. 8.112/1990⁸, which established the Single Legal Regime (RJU). Freire and Pacheco⁹ argue that, prior to this, in the public sector, it was in the Statute of Civil Servants of the Union, established by Decree-Law No. 1^.713 of October 28, 1939 (prior, therefore, to the Consolidation of Labor Laws of 1943), that “some points on the health-work relationship could be observed, such as the provision for retirement, which included accidents at work and illnesses resulting from working conditions” (p. 35). However, according to the authors, the RJU, in terms of work-health relations, only brought “expert, remunerative and compensatory measures for exposure to risk and social security” (p.35). It was with this in mind that Sisosp was drawn up in 2006. In 2008, thematic groups were formed to focus on notions of Occupational Health, which gave rise to the Health and Safety Policy for Federal Public Servants (PASS). With these changes to Sisosp, a system that centralized expert procedures and the figure of the doctor⁹, SIASS came into existence, having as its axes health promotion and surveillance, health expertise, and assistance. In their research, the authors found that, despite the theoretical approximation with the contributions of Workers’ Health, the ideology of Occupational Health prevailed in the constitution of PASS⁹.

On May 7, 2010, Normative Ordinance No. 3 was launched, establishing the Operational Standard for Employee Health (NOSS)¹⁰, the aim of which was to implement actions to monitor work environments and processes and to promote employee health. The sole paragraph of article 3 of the Annex to the Ordinance states that the standard is based on the “interrelationship between the axes of surveillance and promotion, medical expertise and health care of (...) SIASS, in multi-professional teamwork”. In section III, in the part referring to attributions, the text mentions “sharing powers based on the co-management guideline”¹⁰, advocating a “transdisciplinary approach”. This point brings the policy instituted by the Ordinance and endorsed by the norm closer to the field of Occupational Health, referring to the participation of civil servants as a “strategy for valuing their knowledge about work”, which converges with the emphasis on the worker’s knowledge about their craft, as pointed out by activity ergonomics and other work clinics.

However, despite the fact that this reference point underpinned SIASS at its inception, we have increasingly seen it move away from the basic aspects of this field. Thus, there is a disregard for the technical knowledge of multi-professional teams, a Forensic Manual¹¹ that encourages distrust of civil servants’ complaints, and hardly any discussion of the relationship between work situations and illnesses. Aspects related to the possible causal and concausal links¹² between working and becoming ill take second (or third) place. The power of decision to assess the causal link is concentrated in the hands of doctors, regardless of their previous training, which can lead to a restrictive view of the toxicity of work, of mental exhaustion¹³, and of the work itself, considering here the worker’s perspective in terms of the “comfortable conditions”¹⁴(p.2) they experience.

In this sense, this essay, motivated by my experience as a psychologist in the health sector of an educational institution that operates a SIASS unit, proposes a reflection on the contradiction of SIASS, as it currently stands, when it comes to deciding the claims submitted to the health expert. The latter ends up becoming, in practice, medical expertise in the full sense of the term: carried out by doctors, discussed between doctors, guided by doctors, signed off by doctors, with inadequate attention to other health professionals who follow the same cases that come in for evaluation by those other experts.

It is important to add that these reflections have been developed based on the findings of doctoral research¹⁵ carried out by this author, whose objective was to investigate the role of health expertise in SIASS from the point of view of its agents. This research was based on 32 semi-structured interviews with doctors, psychologists, social workers, dentists, and a physiotherapist. At the time, the motivation for the research was related to investigating the possibility of a relationship between the principles of Occupational Health and the expert assessments based on SIASS. The interview script was guided by questions about the interviewees’ conception of the role of health expertise, what their training had been, how they solved their doubts, the difference between their work in the expertise setting and in the care setting, and whether there was teamwork. The question regarding the differences between work in forensics and in care is due to the fact that the SIASS Forensics Manual emphasizes the differentiation between the work of doctors in offices and outpatient clinics and that carried out in forensics, a discussion that is also present, from non-homogeneous perspectives, in articles about the doctor’s job as an expert¹⁶,¹⁷. Since the thesis was defended in 2020, there have been few changes, perhaps with a reduction in the already scarce discussions about cases monitored, and the permanence of medical hegemony in decisions, made possible, paradoxically, by the very design of SIASS.

In this way, the contradiction emphasized here refers to the asymmetry in the technical decisions of the requests, even though, in the implementation of SIASS, co-management and the non-concentration of knowledge were part of its formulation. The system allows only doctors and dentists to sign reports. If there is such a contradiction, to what extent do the effects of its existence affect (and how) civil servants with health claims? This is the question that drives this problematization.

The SIASS contradiction: an asymmetrical reality

It should be emphasized that this essay was written by a psychologist who has been working for 11 years in an SIASS unit, monitoring civil servants in health-disease processes, with various health claims brought for evaluation by medical experts¹⁵. According to this author’s experience, it is possible to say that leave of absence to treat one’s own health and requests for removal for health reasons are the most frequent situations that come to the psychology department of this unit, although there are other reasons for health claims submitted to medical examination.

In these specific situations, the monitoring of the cases, which takes place in partnership (in concomitant consultations or as interconsultations) with Social Service professionals, often reveals reports of suffering linked to institutional contradictions and inconsistencies and to violence at work (whether it is classified as moral harassment at work or not). Some studies have shown that, in the case of civil servants’ health, there is a prevalence of suffering that stems mainly from work organization¹⁸. Processes that can be identified from the notion of mental exhaustion¹³,¹⁹ are quite common, since we can see the diffuse malaise that affects workers as a result of relationships in which there is obstinate disrespect for technical knowledge along with a lack of democratization of decisions and working relationships.

It is important to emphasize here that the notion of mental exhaustion is one of the contributions that can be useful as a theoretical tool for reading the processes of suffering narrated, even when there is no precise diagnosis. The concept is also useful even if these processes do not constitute a recognized medical condition to the point of legitimizing the worker’s suffering and complaint, in other words, in cases of illnesses “without medical explanation”²⁰. Despite the observation of worker suffering linked to the toxicity of situations and the organization of work, narrated in reports that have been repeated over the years by different civil servants, what we notice is that the analysis of health-disease processes on the part of medical experts rarely considers the casual and concausal relationships between work and illness, while they are often present in discussions among non-medical professionals who are dedicated to understanding the relationship between work and disease.

In general, in the original SIASS proposal, when there is suffering at work, the civil servants who suffer from it may, when they so wish, seek care from psychology and social services. These services, in the SIASS unit where the experience described here took place, are based on the Occupational Health approach and sometimes with contributions from other areas related to the “field of health-work relations”³, such as Mental Health and Work²¹ and contributions from some occupational clinics. The professionals who make up the so-called multi-professional team (a suggestive name, as given in the third edition of the Official Federal Civil Servant Health Examination Manual, for the composition of this team, but which does not include the doctor, as if they were not part of the team) often accompany civil servants for periods of weeks or months, listening carefully to their reports, taking note of the details of certain situations, gradually becoming aware of the probable health implications of the experiences of suffering, and offering various forms of guidance related to institutional procedures. When those civil servants arrive at the medical examination, they are often already known to the non-medical professionals because of technical monitoring and deliberate handling from a multi-professional perspective.

It would therefore be reasonable to expect that the medical expert, while listening carefully to the worker’s account at the scene and drawing their own conclusions, would also seek out the other professionals who are following the case. It would be essential to listen to what the professionals who have known the case the longest can contribute, especially as it is not uncommon for them to have a sense of the history of the process of malaise and illness in the specific case, whereas the expert often has only a snapshot of an extremely complex situation.

Furthermore, the doctors who work as experts enter the public service with different specializations and often have no training or familiarity with the reference point of Occupational Health. In the aforementioned study¹⁵, only one of the experts interviewed had a degree in Occupational Medicine, whose precepts are not those of Occupational Health. Furthermore, at the educational institution where I work, the competitive recruitment exam for doctors did not require any kind of specialization. In addition, the issue of “Occupational Health versus Occupational Medicine (...) is scantily discussed in residency programs [in Occupational Medicine]”²² (p.261). Thus, those professionals are not “experts” on the subject of work, i.e., contrary to what the term suggests, they do not have expertise on a considerable list of medical conditions and the work, social, psychological, and institutional issues intrinsic to the multiple situations that come in for evaluation. Medical expertise related to work does not only require clinical knowledge, but also the knowledge of a range of other fields related to legislation and work¹⁸. In fact, it is considered here that, even if they had the training mentioned above, no professional would be able to deal with all the situations that come in for assessment, not only because many of them are complex and require in-depth discussions for responsible and ethical decision-making, but also because it is impossible for one or two professionals, alone or as members of medical boards, to have unequivocal knowledge of everything that comes their way. Certainly, when faced with the most varied of cases, they may have questions that go beyond what their medical knowledge can provide as an answer. And it’s not necessarily the case that consulting identical knowledge (other doctors, WhatsApp groups of SIASS medical experts, for example) is the best way to build more in-depth perspectives on cases marked by great complexity.

However, the experience brought up for discussion here, corroborated by the data obtained in the research previously carried out by the author¹⁵, indicates fewer and fewer moments of effective interdisciplinary work. As an example, we can mention that the resource used by this author, to share information about the cases she has monitored and given the lack or scarcity of channels for discussing cases, has been to write psychological or multi-professional reports detailing the case. This has been the way to communicate what could have been discussed in meetings. Those confidential documents are handed over to the experts, so that they can read and understand the story from another professional perspective, and those reports are not attached to the files, as the information contained therein would expose the worker. After the examination, the experts return the reports, which are filed, and it is common for the doctors not to comment on the outcome of the examination.

It’s worth adding that the resource used above is the result not only of the experience of the gradual reduction of case discussions, but also of the very design of SIASS as an operating system. In SIASS, the health professionals who make up the so-called multidisciplinary team (psychology and social work, for example) do not have access to the medical records of the civil servants they work with. The psychologist depends on a doctor or the system manager (with or without training in the health field) to have access to what doctors record about the civil servants they monitor.

The asymmetry in decision-making moments and the hegemony of one type of knowledge over others is reinforced by the material functioning of the SIASS system. Added to this is the lack of dialogue and interdisciplinary work in a team that communicates little or nothing about cases monitored by all, which means that, in those cases where psychology and social work professionals identify a possible causal link between work and the employee’s illness, the medical team often fails to recognize this link. This points to the contradiction between the theoretical basis that was part of the genesis of SIASS - Occupational Health - and how it is actually structured, given that only doctors and dentists can sign decision-making documents, often failing to listen to the rest of the team. The very fact that the system allows only doctors and dentists to sign indicates the hegemony of biomedical knowledge. Despite the limited debate between doctors, psychologists, and social workers, dental professionals, psychology and social work professionals discuss the relevant referrals and share technical reports from consultations, trying to handle the complex situations that come in for follow-up and opening up space for guidance for civil servants, as well as making themselves heard, whether by experts or by other actors in the institution.

When the causal link between working and becoming ill is disregarded or not investigated at all, even when there is an indication from psychology and social service professionals that it probably exists, impairment of worker’s health can be identified both from an individual and collective perspective. Failure to recognize work-related illness overshadows institutional and organizational issues. It is therefore not difficult to blame the workers themselves for their illness, with diagnoses that individualize their suffering. As Carneiro points out, “illnesses, particularly those triggered or aggravated by work, are seen as controllable by the worker”¹⁸ (p.25). As the author points out, the idea that “workers can control their bodies and, above all, their minds” is common in the world of work¹⁸(p.26). Now, if there is supposedly no relationship between health-disease processes and work organization, and if there is an understanding that getting sick or not getting sick is something that is, to a certain extent, in the hands of the worker themselves, the consequent assumption is that there is a personal problem with the worker who has fallen ill. According to this logic, there would be no need for the institution or organization to look at itself and investigate what it might be producing as a risk factor at work. From the point of view of institutional dynamics, nothing changes, and organizational inconsistencies can continue to reproduce themselves, possibly generating new toxic and painful situations for the worker.

The second problem arising from the invisibility of causal links in health-disease processes refers to the guarantee of rights, which is hindered when these links are not recognized. When an expert records a condition that is clearly linked to work as the primary diagnosis, or when they record an accident at work or a work-related illness, the civil servant’s rights are preserved if they need to take leave to treat their own health. This is because the length of leave, even if it exceeds a total of two years for the same diagnosis or related diagnoses, will not result in compulsory retirement⁸. In other words, this period of time will not entail a possible early retirement due to disability, which is what happens when the federal civil servant generally exceeds this period and there is no indication, according to medical experts, of recovery for work. Moreover, in cases where civil servants have an indication of retirement due to disability and there is a clear, registered link with their work, they will receive their pensions in full, i.e. without any reduction due to the proportionality of their contribution time. However, if there is no such recognition and the need for disability retirement arises, the retired civil servant will receive their pension in proportion to their contribution time, which often means a drastic reduction in their monthly income, in a circumstance in which they will need to spend more, given that some health condition has caused their early retirement, probably requiring treatment, rehabilitation, medication costs.

Final considerations

The hegemony of medical knowledge in health assessments, besides being contradictory to the foundations that established SIASS and NOSS itself¹⁰, has two main problems. The first is that, by disregarding the contributions of other health knowledge, built up by professionals from different backgrounds, medical decisions tend to neglect possible aspects that would make it possible to establish a causal link between illness and work. As a result, leaves of absence that could be recognized as deriving from work-related illnesses end up being disconnected from that origin, which causes financial losses to the civil servant, especially regarding retirement time. This is because, contrary to what happens in cases recognized as occupational illnesses or accidents at work, the time off work is deducted from the two-year limit set by law for retirement on grounds of disability. The participation of professionals from different areas, as proposed by the transdisciplinary approach provided for in the standard itself, does not in itself guarantee that the risk factors and causal links between work and illness will be properly investigated. However, it is believed that by broadening the number and quality of perspectives on the complex situations experienced in the workplace, the chances of identifying aspects that would otherwise remain invisible or poorly understood are increased. As already mentioned, when a civil servant takes time off for a diagnosis that is not classified as a work-related illness or accident, the time off starts to be deducted from the legal limit of two years. Although, in many cases, that absence is not directly related to the work, an important question arises: what if the multiple aspects involved in the illness - those that make up the multifactorial toxicity of the work environment, work organization, work relationships, as well as the difficult nature of the work - are not perceived or investigated in a systematic way? In this setting, the loss solely affects the civil servant.

The other problem relates to the fact that medical decisions made in isolation, without the collective construction of diagnoses by a team, can generate distorted data on the causes of sick leave. Diagnoses that should be secondary to work situations end up being treated as primary, individualizing illness and preventing the institution from recognizing its own toxic and painful dynamics. This compromises the possibility of promoting real changes in work environments and relationships, making an effective approach to employee health care unfeasible, especially from the perspective of Collective Health. As a result, a chain of harm and hardship at work is perpetuated while remaining invisible, without causing any transformation. This reveals a contradiction between the original foundations of SIASS and the way it has been increasingly operationalized.

References

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• Information on academic work:
  Essay based on the doctoral thesis of the author Vivian Heringer Pizzinga entitled “Perícias em saúde no SIASS: Conflitos entre o cuidado e o controle (Health expertise at SIASS: Conflicts between care and control)”, presented in 2020 to the Postgraduate Program in Collective Health of the Institute of Social Medicine of the State University of Rio de Janeiro.
• Data availability:
  The entire data set supporting the results of this study has been published in the article itself.
• Statement on the use of Artificial Intelligence:
  The author declares that no artificial intelligence tools were used to prepare the article.
• Presentation at a scientific event:
  The author states that the study has not been presented at a scientific event.
• Funding:
  The author declares that the study was not subsidized.

Edited by

• Responsible editors:
  Maria Maeno
  Raoni Rocha Simões

Data availability

The entire data set supporting the results of this study has been published in the article itself.

Publication Dates

• Publication in this collection
  03 Apr 2026
• Date of issue
  2026

History

• Received
  03 July 2025
• Reviewed
  29 Sept 2025
• Accepted
  12 Oct 2025